NABH Documentation Requirement

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Documentation Requirements for Hospital
Accreditation

• -By Global Manager Group

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What is Accreditation?
Accreditation is basically a framework, which
helps healthcare organization to establish
objective systems aimed at patient safety and
quality of care. Documentation plays an important
role in defining of such systems. In general, the
organization will need to establish objective and
dynamic system incorporating requirements given
in the standard. These systems defined,
implemented, owned by the staff and finally
provide objective evidence of compliance.

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NABH Certification for Hospital Accreditation
Objective of NABH Certification is to operate
accreditation and allied programs in
collaboration with stakeholders focusing on
patient safety and quality of healthcare. NABH
has developed Pre Accreditation Entry Level
certification standards, in consultation with
various stake holders in the country, as a
stepping stone for enhancing the quality of
patient care and safety.

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How one should apply for NABH Accreditation?
The organizations can obtain the application form
for NABH Accreditation from NABH Secretariat or
download it from the web-site. The application
form should be accompanied with the required
application fee. Hospitals should also submit a
signed document Terms and Conditions for
Maintaining NABH Accreditation'. The same can be
downloaded from the website. For more details
please see Accreditation Documents'.

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NABH Documentation
NABH Documentation, serves as a point of
reference for everyone in the organization. While
their personal perspectives may be respected, the
documented system and processes have to be
complied with consistently in the organization by
everyone. A NABH Documented policy, process and
procedure become a single source of truth in an
organizational set-up.

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Importance of Manual in NABH Documentation
Quality manual is a document in the organization
that contains the total quality program including
general information about organization, its
business its vision mission statements, its
quality policy, quality objectives, quality
standard applied, departmental work units
policies and procedures, SOPs, forms formats
used by organization, quality monitoring
protocols indicators and the corrective
preventive actions that the organization takes to
improve quality.

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NABH Policy in Documentation

• NABH Policy commits to achieve quality services
  through the Quality Management System while
  complying with all applicable regulatory
  requirements.
• Objectives for NABH Policy
• To maintain the quality of ophthalmic services
  in accordance with international standards.
• Optimum utilization of infrastructural
  facilities including manpower.
• To ensure continued patient satisfaction
  through delivery of high class Medicare with a
  personal touch.
• To ensure high levels of staff satisfaction and
  motivation and facilitate continuous enhancement
  of knowledge and skills through constant learning
  and training initiatives.

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NABH System Procedures

• Requirement of Procedures for NABH Certification
  are as follows
• Management Review
• Document And Data Control
• Corrective And Preventive Action
• Control Of Quality Records
• Internal Quality Audit
• Control Of Monitoring Measuring Equipment
  Training
• Control Of NonConforming Products / Services

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NABH SOPs

• Requirement of Standard Operating Procedures for
  NABH Certification are as follows
• AAC(Access, Assessment and Continuity of Care)
• COP (Care of Patients)
• CQI (Continuous Quality Improvement)
• General
• MOM (Management of Medications)
• PRE (Patient Rights and Education)

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NABH Audit Checklist
NABH Audit Checklist covers audit questions to be
used for hospital system auditing for objectively
evaluate the adherence of system by functional
heads to establish processes. It also includes
audit questions as a quick reference for all
related work areas of the hospital. It will be
very good tool for the auditors to make audit
Questionnaire while auditing and make
effectiveness in auditing in the hospital.

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Benefits of NABH Accreditation

• Accreditation benefits all Stake Holders.
  Patients are the biggest beneficiaries.
  Accreditation results in high quality of care and
  patient safety. The patients get services by
  credential medical staff. Rights of patients are
  respected and protected. Patient satisfaction is
  regularly evaluated.
• Accreditation to a Hospital stimulates
  continuous improvement. It enables hospital in
  demonstrating commitment to quality care. It
  raises community confidence in the services
  provided by the hospital. It also provides
  opportunity to healthcare unit to benchmark with
  the best.

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• The Staff in an accredited hospital are
  satisfied lot as it provides for continuous
  learning, good working environment, leadership
  and above all ownership of clinical processes. It
  improves overall professional development of
  Clinicians and Paramedical staff and provides
  leadership for quality improvement within
  medicine and nursing.
• Accreditation provides an objective system of
  empanelment by insurance and other Third Parties.
  Accreditation provides access to reliable and
  certified information on facilities,
  infrastructure and level of care.

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NABH Documentation Kit By Global Manager Group

• Hospital Manual (08 files)
• Department Manual (47 Files)
• System Procedures (08 system procedures)
• Health and Safety Procedures
• Process Approach
• Standard Operating Procedures (SOPs)
• System Formats
• NABH Audit checklist

Free DEMO Download

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introduces Online Consultancy by offering
International System Certification Documentation
and Auditor Training Packages.
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